Protective Effects of ß-Blockers on Bone in Older Adults with Dementia.

Increased ß-adrenergic receptor activity has been hypothesized to cause bone loss in those with dementia. We investigated the effect of long-term ß-blocker use on rate of bone loss in older adults with dementia. We used a linear mixed-effects model to estimate the relationship between long-term ß-blocker use and rate of bone loss in participants from the Health Aging and Body Composition study. Records of 1198 participants were analyzed, 44.7% were men. Among the men, 25.2% had dementia and 20.2% were on ß-blockers, while in the women, 22.5% had dementia and 16.6% received ß-blockers. In the 135 men with dementia, 23 were taking ß-blockers, while 15 of 149 women with dementia were using ß-blockers. In men with dementia, ß-blocker users had 0.00491 g/cm2 less bone mineral density (BMD) loss per year at the femoral neck (i.e., 0.63% less loss per year) than non-users (p < 0.05). No differences were detected in women with or without dementia and men without dementia. ß-blockers may be protective by slowing down bone loss in older men with dementia.

Effect of Quarantine on Body Weight Among Residents of Assisted Living Facilities During the COVID-19 Pandemic.

Assisted living facility (ALF) residents are at greater risk of declining health and death from coronavirus disease 2019 (COVID-19) due to advanced age, frailty, chronic conditions, and transmission prevention methods. One method, room quarantine, can lead to isolation and potential weight changes. Continuous room quarantine was mandated by the state for all nursing home and ALF residents. The objective of the current study was to determine the degree and significance of weight loss during quarantine through retrospective chart review and use these findings to guide a quality improvement project. Pre-and post-COVID-19 weights were compared for 53 house call program residents. Descriptive statistics and logistic regression were used. This small convenience sample demonstrated significant weight loss for 40% of ALF residents quarantined during the COVID-19 pandemic. Males showed a greater risk of significant weight loss. Weight loss of 5% in 1 month is considered problematic in older adults. As quarantine measures continue to be used for COVID-19 outbreaks, weight changes, particularly among males, need to be monitored and reported for intervention. [Journal of Gerontological Nursing, 49(9), 29-34.].

Diuretic use and risk of falls in older women with urinary incontinence.

OBJECTIVE: To determine the association between diuretic use and falls in community-dwelling older women with urinary incontinence (UI). METHODS: We conducted an analytic cross-sectional study using patients' electronic medical records. Patients were women with UI, 65 years or older seen at a urogynecology clinic between January 1, 2018 and September 30, 2019. We used logistic regression analysis to explore the associations between falls and diuretic use. RESULTS: The study included 108 women, mean age of 75.2 ±7.5 years. Twenty-two (20%) reported one or more falls within the past year and 32 (30%) were diuretic users. Fall prevalence in diuretic users and non-users were 25% (8/32) and 18.4% (14/76), respectively. Diuretic use was not associated with falls (OR = 0.74, 95%CI = 0.22-2.52). Post-hoc analysis revealed inadequate sample size. CONCLUSIONS: Diuretics use may not be a risk factor for falls in ambulatory older women with UI. A larger sample will be needed to confirm.

Chronic inflammatory back pain commencing late in life: a neglected concept.

Chronic inflammatory back pain (CIBP) occurs in up to one-third of those with chronic back pain. Criteria for diagnosis of inflammatory back pain include an onset below 50 years. Using the US National Health and Nutrition Examination Survey data for 2009-2010, we showed that 3% of adults aged 50-69 years have features of CIBP with onset on or after 50 years. There is little information in the literature on CIBP of late onset. Patients with late onset CIBP may be falling through the cracks.

Patient-Reported Continuity of Care and Functional Safety Concerns After Inpatient Cancer Rehabilitation.

BACKGROUND: Patients with cancer have been noted to have inadequate continuity of care after discharge from hospital. We sought to assess patient-reported continuity of care and functional safety concerns after acute inpatient rehabilitation. METHODS: This was a prospective study that used cross-sectional surveys at a National Cancer Institute Comprehensive Cancer Center. All patients who were admitted to acute inpatient rehabilitation from September 5, 2018, to February 7, 2020, met the inclusion criteria, and completed two surveys (assessing continuity of care and functional safety concerns) upon discharge and 1 month after discharge were included in the study. RESULTS: A total of 198 patients completed the study, and no major concerns were reported by the patients. The greatest concern was a lack of adequate communication management among different providers, reported by only 10 (5.0%) patients. The combined fall and near-fall rate within 1 month after discharge was (25/198) 13%. Brain metastasis, a comorbidity of depression, and a history of falls were significantly associated with a higher risk of falls or near falls within 1 month after discharge. CONCLUSION: Although overall patients with cancer reported adequate continuity of care and feeling safe to function at home after acute inpatient rehabilitation, it is important to be aware that fall or near-fall events within 1 month after acute inpatient rehabilitation are associated with brain metastasis, comorbidity of depression, and a history of falls. Thus, patients with these risk factors may benefit from including more focused fall prevention education and interventions. IMPLICATIONS FOR PRACTICE: Patients with cancer often have extensive problems that require care from multiple health care providers simultaneously, and a high level of coordination is needed for adequate transition of care from the inpatient to the outpatient setting. This transition of care period is prone to inadequate continuity of care and, for older adults, a particular risk for falls. Assessment for risk of fall is also an important factor to consider when evaluating patients to continue oncology treatments. There is a gap in knowledge regarding patient-reported continuity of care and functional safety concerns after acute inpatient cancer rehabilitation.

Delirium Among Hospitalized Older Adults With Acute Heart Failure Exacerbation.

BACKGROUND: Delirium among older adults hospitalized with acute heart failure is associated with increased mortality. However, studies concomitantly assessing the association of delirium with both clinical and economic outcomes in this population, such as mortality, hospital cost, or length of stay, are lacking. METHODS AND RESULTS: We conducted a retrospective observational study using National Inpatient Sample data from 2011 to 2014. Using multivariable logistic regression, we assessed the association of delirium with in-hospital mortality, then estimated the incremental hospital cost and excessive length of stay adjusting for demographic and clinical factors using multivariable generalized linear regression. The association of other medical complications on clinical and economic outcomes was also assessed. A total of 568,565 (weighted N = 2,826,131) hospitalizations of patients 65 years or older with acute heart failure from 2011 to 2014 were included in the final analysis. The reported prevalence of delirium was 4.53%. After multivariable adjustment, delirium was associated with a 2.35-fold increase in the odds of in-hospital mortality (95% confidence interval [CI] 2.23-2.47), which was lower than the odds ratio for sepsis/septicemia (5.36; 95% CI, 5.02-5.72) or respiratory failure (4.53; 95% CI, 4.38-4.69), but similar to that for acute kidney injury (2.39; 95% CI, 2.31-2.48) and higher than for non-ST elevation myocardial infarct (1.57; 95% CI, 1.46-1.68). Delirium increased the total hospital cost by $4,262 (95% CI, $4,002-4,521) and the length of stay by 1.73 days (95% CI, 1.68-1.78), which was slightly lower than, but similar to, acute kidney injury ($4,771; 95% CI, $4,644-4,897) and 1.82 days (95% CI, 1.79-1.84), and higher than non-ST elevation myocardial infarct ($1,907; 95% CI, $1,629-2,185) and 0.31 days (95% CI, 0.25-0.37). CONCLUSIONS: Delirium was associated with increased in-hospital mortality, total hospital cost, and length of stay, and the magnitude of the effect was similar to that for acute kidney injury. Enhanced efforts to prevent delirium are needed to decrease its adverse impact on clinical and economic outcomes for hospitalized older adults with acute heart failure.

Quality of Life Assessment in Older Adults with Dementia: A Systematic Review.

INTRODUCTION: In the absence of a cure, dementia is often managed by minimizing risk factors contributing to quality of life (QOL). Attitudes to dementia in older adults may differ from those in relatively younger adults. The aim was to conduct a systematic review of the literature to determine how QOL was assessed in adults, 65 years and older with dementia, and identify factors that influence the reported scores. METHODS: A systematic review of full-text articles addressing QOL in older adults with dementia, published in English from January 1995 to September 2020, was conducted using PubMed and PsycINFO. We included studies that assessed QOL and involved participants 65 years and older. Studies were evaluated for inclusion by 2 independent pairs of reviewers. We assessed the quality of the studies using the Joanna Briggs Institute's Critical Appraisal Checklist. Study characteristics and findings were summarized. Analysis was by narrative synthesis. We identified social and clinical factors influencing QOL scores. RESULTS: Of the 1,010 articles identified, 19 met the inclusion criteria. These 19 studies involved 6,279 persons with dementia, with sample sizes from 32 to 1,366. Mean age of participants ranged from 77.1 to 86.6 years. Five measurement tools were identified; Quality of Life in Alzheimer Disease (QOL-AD), Alzheimer Disease-Related Quality of Life (ADRQL), Quality of Life in Late-Stage Dementia (QUALID), QUALIDEM (a dementia-specific QOL tool), and DEMQOL (health-related QOL for people with dementia). Self-ratings of QOL were higher than proxy ratings. Factors commonly influencing self-ratings of QOL included depression, functional impairment, and polypharmacy. Common factors that influenced proxy ratings included functional impairment, presence of neuropsychiatric symptoms, cognitive impairment, and caregiver burden. CONCLUSION: In evaluating QOL in dementia, self- and proxy reports may complement each other to ensure that all perspectives are addressed.

Shorter length of hospital stay for hip fracture in those with dementia and without a known diagnosis of osteoporosis in the USA.

BACKGROUND: About 50% of all hospitalized fragility fracture cases in older Americans are hip fractures. Approximately 3/4 of fracture-related costs in the USA are attributable to hip fractures, and these are mostly covered by Medicare. Hip fracture patients with dementia, including Alzheimer's disease, have worse health outcomes including longer hospital length of stay (LOS) and charges. LOS and hospital charges for dementia patients are usually higher than for those without dementia. Research describing LOS and acute care charges for hip fractures has mostly focused on these outcomes in trauma patients without a known pre-admission diagnosis of osteoporosis (OP). Lack of documented diagnosis put patients at risk of not having an appropriate treatment plan for OP. Whether having a diagnosis of OP would have an effect on hospital outcomes in dementia patients has not been explored. We aim to investigate whether having a diagnosis of OP, dementia, or both has an effect on LOS and hospital charges. In addition, we also report prevalence of common comorbidities in the study population and their effects on hospital outcomes. METHODS: We conducted a cross-sectional analysis of claims data (2012-2013) for 2175 Medicare beneficiaries (≥65 years) in the USA. RESULTS: Compared to those without OP or dementia, patients with demenia only had a shorter LOS (by 5%; P = .04). Median LOS was 6 days (interquartile range [IQR]: 5-7), and the median hospital charges were $45,100 (IQR: 31,500 - 65,600). In general, White patients had a shorter LOS (by 7%), and those with CHF and ischemic heart disease (IHD) had longer LOS (by 7 and 4%, respectively). Hospital charges were 6% lower for women, and 16% lower for White patients. CONCLUSION: This is the first study evaluating LOS in dementia in the context of hip fracture which also disagrees with previous reporting about longer LOS in dementia patients. Patients with CHF and IHD remains at high risk for longer LOS regardless of their diagnosis of dementia or OP.

Paget Disease of Bone for Primary Care.

Paget disease of bone is a benign disorder characterized by focal areas of increased bone turnover in one or more skeletal sites. It usually affects older adults, and men are at a higher risk than women. Any bone may be affected, but the disease has a high preference for the pelvis, spine, skull, and long bones. Pain is the most common symptom, and presentation of the disease may depend on which bones are affected, the extent of involvement, and the presence of complications. Paget disease of bone may be asymptomatic, and suspicion arises from incidental findings of elevated serum alkaline phosphatase levels on routine blood work or abnormalities on imaging tests performed for an unrelated cause. Evidence-based guidelines recommend the use of plain radiography and serum alkaline phosphatase testing for initial diagnosis and radionuclide scans for delineation of the extent of disease. Treatment with nitrogen-containing bisphosphonates is recommended in active disease or when risk of complications is possible. Complications of the disease include arthritis, gait changes, hearing loss, nerve compression syndromes, and osteosarcoma. Total serum alkaline phosphatase is the suggested marker for assessing treatment response when high bone turnover occurs, and it should be measured at three to six months to evaluate initial response. Early diagnosis of Paget disease of bone remains key to its management because patients generally have a good prognosis if treatment is initiated before major complications arise. The primary care physician may need to consult with a specialist for confirmation of diagnosis and initiation of treatment.

Lower femoral neck bone mineral density (BMD) in elderly women not on statins.

Coronary artery disease (CAD) and osteoporosis, the two most frequently occurring chronic diseases of aging populations, share many risk factors including lack of estrogen, smoking, and low physical activity. CAD and low bone mineral density (BMD) are strongly associated. Statins, (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors), are used to prevent and treat CAD and have been associated with high BMD. This cross-sectional study examined associations of BMD with statin use and nonuse in elderly women with or without CAD. Multivariate regression analyses were conducted on 185 women aged ≥60 years who were referred between October 2010 and March 2015 to a geriatric osteoporosis clinic in Houston, Texas, for compromised skeletal health. Compared to the control group (without CAD and without statin use), patients with CAD and no statin use were more likely to have lower femoral neck BMD (ß: -0.46, 95% confidence interval: -0.75 to -0.18). The BMD of patients taking statins, regardless of presence of CAD, was similar to that of the control group. Statins may be protective in preventing bone loss in elderly women suffering from CAD. Prospective trials are warranted to determine if continued use of statins in them would help prevent both CAD and bone loss.

Association of Selective Serotonin Reuptake Inhibitors and Bone Mineral Density in Elderly Women.

Depression and osteoporosis are 2 common comorbidities in geriatric patients. There are concerns about the deleterious effects of selective serotonin reuptake inhibitor (SSRI) antidepressant use on bone mineral density (BMD). We examined the association between SSRI use and BMD in elderly women (≥65 yr) referred to a geriatric osteoporosis clinic for bone health evaluation. Cross-sectional analyses using the general linear model were performed on data collected retrospectively from August 2010 to April 2015. A total of 250 women were seen during the study period. Of these, 140 women had complete data on BMD measurements: 22 (15.7%) used an SSRI and 118 (84.3%) did not. The 2 groups, SSRI users and SSRI nonusers, did not differ significantly across any of the covariates tested (age, ethnicity, body mass index, and past and present osteoporosis treatment medications). After adjusting for covariates, there was no difference in the BMDs at the femoral neck (p = 0.887) or the spine (p = 0.275) between the 2 groups. Similarly, no difference was seen in the T-scores between SSRI users and nonusers at the femoral neck (p = 0.924) or at the spine level (p = 0.393). Our study did not show an association between SSRI use and BMD among elderly women referred for bone health evaluation. Other studies in the literature have been inconclusive, and therefore, robust longitudinal studies are needed to further assess the interaction between SSRI use and predictors of fracture such as BMD, bone turnover markers, and genes involved in bone turnover. Until then, clinicians should closely monitor the bone health of long-term SSRI users.

Lumbar Spine Trabecular Bone Score (TBS) Reflects Diminished Bone Quality in Patients With Diabetes Mellitus and Oral Glucocorticoid Therapy.

Trabecular bone score (TBS) is a texture parameter that measures the grayscale variation within dual-energy X-ray absorptiometry (DXA) images, and has been shown to significantly correlate with the 3-dimensional bone microarchitecture. The objective of this study was to determine whether TBS is a better clinical tool than traditionally used bone mineral density (BMD) to detect the skeletal deterioration seen in patients with diabetes (DM), patients undergoing oral glucocorticoid (GC) therapy, and patients who are both diabetic and taking steroids (GC + DM). We performed retrospective, cross-sectional study using DXA images of patients who visited UTHealth Department of Internal Medicine DXA clinic in Houston, TX, from May 30, 2014 to May 30, 2016. A total of 477 men and women, who were 55 years or older, were included in the study. Lumbar spine (LS) BMD and TBS were collected. Electronic medical records were reviewed to collect clinical information for each patient. When both men and women were analyzed as a single group, LS-BMD was significantly higher in the diabetic group than in the control group (1.14 vs 1.10, p = 0.038), whereas mean TBS of L1-L4 was significantly lower in the diabetic group (1.21 vs 1.26, p = 0.004). LS-TBS was also significantly lower in diabetic women than in nondiabetic women (1.20 vs 1.26, p = 0.002). Receiver operating characteristic curves and areas under the curve indicated that LS-TBS provided better ability than LS-BMD to discriminate between control subjects and those in the DM, GC, or GC + DM groups (areas under the curve between 0.645 and 0.697, p < 0.010 for all). LS-TBS is a BMD-independent parameter that is capable of capturing a larger portion of bone quality deterioration undetected by BMD alone in patients with DM and undergoing oral GC therapy.

Trabecular Bone Score Is a Valuable Addition to Bone Mineral Density for Bone Quality Assessment in Older Mexican American Women With Type 2 Diabetes.

Altered bone quality due to the underlying metabolic changes of type 2 diabetes (T2D) has been hypothesized to affect bone strength, leading to increased fracture risk in patients with T2D. Lumbar spine trabecular bone score (LS-TBS), an indirect measure of trabecular microarchitecture, provides information on bone quality and has been associated with T2D. However, trabecular bone score (TBS) is also affected by demographic patterns and body size, and is expected to be different in people from various ethnic or racial backgrounds. Therefore, it is important to understand associations between T2D and TBS for each ethnic or racial group separately. Although the relationship between TBS and age has been reported to be similar between non-Hispanic Caucasians and Mexican Americans (MAs), data on associations of LS-TBS with T2D in older MAs are lacking. Here, we report associations between TBS and T2D in 149 older MA men and women. Participants are part of a cohort known as the Cameron County Hispanic Cohort in Texas who have high prevalence of obesity and poor glycemic control. Bone mineral density was not altered for MA women with T2D, but was significantly higher in MA men with T2D compared with MA men without diabetes. Low LS-TBS was associated with T2D in women in our study. Although low TBS was associated with older age in men, TBS did not show any significant association with T2D for men. These results are similar to those found in other studies of non-Hispanic whites with diabetes. LS-TBS may add value in diagnosing poor bone quality in older MA women with T2D regardless of bone mineral density scoring.

Impact of Polypharmacy on Seniors' Self-Perceived Health Status.

OBJECTIVES: Polypharmacy is common among older patients and is linked to increased risk of adverse health outcomes. This study aimed to explore the association of polypharmacy and self-perceived health status (SPHS) among geriatric patients. METHODS: This cross-sectional analysis of longitudinal observational research used national survey data from 2005-2008. Multivariate logistic regressions examined the likelihood of having a good/poor SPHS and polypharmacy. Medical Expenditure Panel Survey data provided by Agency for Healthcare Research and Quality were used in this study. Overall, SPHS was assessed using the Medical Expenditure Panel Survey health and well-being variable. Polypharmacy status was defined when patients were taking ≥5 medications. RESULTS: The study included a total of 102,309,656 weighted individuals reported from the survey of 4775 actual individuals from 2005-2008. Patients' mean age was 74.7 years (standard error ± 0.138), and 58.1% were women, 87.3% were white, 55.2% were married, and 37.3% were from the southern region of the United States. Approximately 69.4% of patients reported polypharmacy. The most prevalent disease reported was hypertension (62.7%). We evaluated demographic and clinical characteristics based on SPHS and polypharmacy status. Overall, 78.09% of seniors reported their SPHS as good, whereas 21.91% reported their SPHS as poor. Among polypharmacy users, 72.52% reported good SPHS and 27.48% reported poor SPHS. Among older adults who were nonpolypharmacy users, 90.8% reported good and 9.02% reported poor SPHS. Logistic regression adjusted for demographic and socioeconomic factors showed that nonpolypharmacy users are approximately three times more likely to report their SPHS as good (odds ratio 2.75; 95% confidence interval 2.12-3.57, P < 0.001). CONCLUSIONS: Nonpolypharmacy users perceived their health status to be better than did polypharmacy users. Interventions to reduce polypharmacy may improve SPHS. One such intervention, medication reconciliation, may have a positive ripple effect on the patient-centered care delivery system.

Losartan increases bone mass and accelerates chondrocyte hypertrophy in developing skeleton.

Angiotensin receptor blockers (ARBs) are a group of anti-hypertensive drugs that are widely used to treat pediatric hypertension. Recent application of ARBs to treat diseases such as Marfan syndrome or Alport syndrome has shown positive outcomes in animal and human studies, suggesting a broader therapeutic potential for this class of drugs. Multiple studies have reported a benefit of ARBs on adult bone homeostasis; however, its effect on the growing skeleton in children is unknown. We investigated the effect of Losartan, an ARB, in regulating bone mass and cartilage during development in mice. Wild type mice were treated with Losartan from birth until 6 weeks of age, after which bones were collected for microCT and histomorphometric analyses. Losartan increased trabecular bone volume vs. tissue volume (a 98% increase) and cortical thickness (a 9% increase) in 6-weeks old wild type mice. The bone changes were attributed to decreased osteoclastogenesis as demonstrated by reduced osteoclast number per bone surface in vivo and suppressed osteoclast differentiation in vitro. At the molecular level, Angiotensin II-induced ERK1/2 phosphorylation in RAW cells was attenuated by Losartan. Similarly, RANKL-induced ERK1/2 phosphorylation was suppressed by Losartan, suggesting a convergence of RANKL and angiotensin signaling at the level of ERK1/2 regulation. To assess the effect of Losartan on cartilage development, we examined the cartilage phenotype of wild type mice treated with Losartan in utero from conception to 1 day of age. Growth plates of these mice showed an elongated hypertrophic chondrocyte zone and increased Col10a1 expression level, with minimal changes in chondrocyte proliferation. Altogether, inhibition of the angiotensin pathway by Losartan increases bone mass and accelerates chondrocyte hypertrophy in growth plate during skeletal development.

Protein intake and lumbar bone density: the Multi-Ethnic Study of Atherosclerosis (MESA).

Dietary protein has been shown to increase urinary Ca excretion in randomised controlled trials, and diets high in protein may have detrimental effects on bone health; however, studies examining the relationship between dietary protein and bone health have conflicting results. In the present study, we examined the relationship between dietary protein (total, animal and vegetable protein) and lumbar spine trabecular volumetric bone mineral density (vBMD) among participants enrolled in the Multi-Ethnic Study of Atherosclerosis (n 1658). Protein intake was assessed using a FFQ obtained at baseline examination (2000-2). Lumbar spine vBMD was measured using quantitative computed tomography (2002-5), on average 3 years later. Multivariable linear and robust regression techniques were used to examine the associations between dietary protein and vBMD. Sex and race/ethnicity jointly modified the association of dietary protein with vBMD (P for interaction = 0·03). Among white women, higher vegetable protein intake was associated with higher vBMD (P for trend = 0·03), after adjustment for age, BMI, physical activity, alcohol consumption, current smoking, educational level, hormone therapy use, menopause and additional dietary factors. There were no consistently significant associations for total and animal protein intakes among white women or other sex and racial/ethnic groups. In conclusion, data from the present large, multi-ethnic, population-based study suggest that a higher level of protein intake, when substituted for fat, is not associated with poor bone health. Differences in the relationship between protein source and race/ethnicity of study populations may in part explain the inconsistent findings reported previously.

Fracture risk assessment in older adults using a combination of selected quantitative computed tomography bone measures: a subanalysis of the Age, Gene/Environment Susceptibility-Reykjavik Study.

Bone mineral density (BMD) and geometric bone measures are individually associated with prevalent osteoporotic fractures. Whether an aggregate of these measures would better associate with fractures has not been examined. We examined relationships between self-reported fractures and selected bone measures acquired by quantitative computerized tomography (QCT), a composite bone score, and QCT-acquired dual-energy X-ray absorptiometry-like total femur BMD in 2110 men and 2682 women in the Age, Gene/Environment Susceptibility-Reykjavik Study. The combined bone score was generated by summing gender-specific Z-scores for 4 QCT measures: vertebral trabecular BMD, femur neck cortical thickness, femur neck trabecular BMD, and femur neck minimal cross-sectional area. Except for the latter measure, lower scores for QCT measures, singly and combined, showed positive (p < 0.05) associations with fractures. Results remained the same in stratified models for participants not taking bone-promoting medication. In women on bone-promoting medication, greater femur neck cortical thickness and trabecular BMD were significantly associated with fracture status. However, the association between fracture and combined bone score was not stronger than the associations between fracture and individual measures or total femur BMD. Thus, the selected measures did not all similarly associate with fracture status and did not appear to have an additive effect on fracture status.

Improving patient safety through mandatory quality improvement (QI) education in a family medicine residency programme.

Although the American College of Graduate Medical Education (ACGME) requires that medical trainees acquire competencies in patient safety and quality improvement (QI), no standard curriculum exists. We envisaged that a sustainable QI curriculum would be a pragmatic way to improve residents' skills and competence in patient safety. Our aim was to develop and evaluate a patient safety-oriented QI curriculum in an established family medicine residency programme. A patient safety curriculum fulfilling ACGME requirements was developed and implemented in a family residency programme. The curriculum comprised didactics, self-paced online modules, experiential learning through individual QI projects, and mortality and morbidity conferences. The programme was evaluated using a survey at the end of its first year. We assessed knowledge on patient safety and QI, confidence in discussing safety concerns with peers, and ability to recognise safety gaps and initiate corrective actions. We also assessed the perception of the programme's relevance to the residents' training. All 36 residents participated, 19 completed the evaluation survey. Fifteen (79%) respondents reported learning more about the causes of medical errors, 42% could report safety concerns and 26% could recognise quality gaps. In addition, 58% felt the curriculum increased their confidence in discussing patient safety concerns with peers while 74% found the curriculum very relevant to their training. Some participants described the programme as 'very productive'. Embedding a QI curriculum into the ongoing residency training may be a realistic approach to training family medicine residents with no prior formal QI training.

Risk of Depression in a Suburban Primary Care Setting Before and During the COVID-19 Pandemic.

INTRODUCTION: Major depression is a common disorder affecting millions of adults each year. Many population-based surveys showed an increase in the number people with symptoms of depression at the onset of the COVID-19 pandemic. Our aim was to determine and compare the prevalence of depression risk in a primary care setting before and during the COVID-19 pandemic. METHODS: We conducted a cross-sectional study based on retrospective review of medical records from a large suburban primary care clinic. Records of adults 18 years and older, seen between January 1, 2019 and December 31, 2020 and who had also been screened for depression using the 9-item Patient Health Questionnaire (PHQ-9) were analyzed. RESULTS: Adults 18 years and older who completed the PHQ-9 assessment in 2019 and 2020 were 5078 and 4338, respectively. Risk of depression was 18.2% in 2019 and 14.8% in 2020 (P < .001). In adults under 50 years and those 50 years and older, depression risk was 20.7% versus 15.3% in 2019 (P < .001) and 17.3% versus 12.6% in 2020 (P < .001), respectively. In females, depression risk was 20.0% in 2019 and 16.8% in 2020 (P < .01), and in males, 14.1% in 2019 and 10.6% in 2020 (P < .01). CONCLUSION: Although our results did not reflect the published literature reporting a higher prevalence of depression during the COVID-19 pandemic, they were consistent with reports of increased risk in females and younger adults.

Negotiating a new chair package: context and considerations.

Negotiating a resource package as a potential new department chair is common practice in academic medicine. The foundations for this negotiation include the historical presence of the department in relation to the broader institution, projections for future growth, accounting for mission/vision, resource needs (space, personnel, finances, etc), faculty and staff development, and external partnerships within and outside the institution. Despite similarities in this process across departments, many nuances influence the development of a specific new chair package, such as, department size; desires, perspectives and talents of the incoming chair, the department faculty, the medical school and dean; prevailing agendas and mission imperatives; and the overall priorities of the institution. With strategy and forethought, a new chair package can promote a successful chair tenure and departmental growth. Assembled through the Association of Departments of Family Medicine with input from several dozen department chairs and senior leaders, this is intended to serve as a practical guide to new chair packages for chair candidates.